NCC220316_FRO Submitted_20220126

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
1. Project Name Mebane Street Family Fare
2. Location of land -disturbing activity: County Alamance City or Township Burlington
Highway/Street S Mebane Street Latitude 36.070391 Longitude-79.467283
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5 acres
6. Amount of fee enclosed: $ 285.00 . The application fee of $225 for the initial 2 acres
plus $60 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $645).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lee Barnes E-mail Address Ibarnes familyfarecstores.com
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
M.M. Fowler, Inc. 919-309-2925 n/a
Name Telephone Fax Number
4220 Neal Road 4220 Neal Road
Current Mailing Address Current Street Address
Durham, NC 27705 Durham, NC 27705
City State Zip City State Zip
10. Deed Book No. 4268 Page No. 749 Provide a copy of the most current deed.
11. Tax Map No. 12-14-43 Block Lot No.
12. Parcel ID 120791 etal. (PB82 PG282) GPIN (State ID) 8864149846
Part B.
1. Person(s) or firm(s) who is financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
M.M. Fowler, Inc. [e-mail]
Name E-mail Address
4220 Neal Road 4220 Neal Road
Current Mailing Address Current Street Address
Durham, NC 27705 Durham, NC 27705
City State Zip City State Zip
Telephone [phone] Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
n/a
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information sho Id there be any change in the information provided herein.
Type o print na Title or Authority
Signatur6 Date
a Notary Public of the County of -1)��C�c�.y�
State of North Carolina, hereby certify that V� L i�G�`C��C �� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this _day of L)c. 20�_
Notary
Seal p'CAR
Y =
`+ My commission expiresIJ
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THE LEADS GROUP PA
5657
THE LEADS GROUP PA
LAND ENGINEERING AND DEVELOPMENT SERVICES
505 E DAVIS ST.
BURLINGTON. NC 27215
[phone]
PAY
TO THE Two hundred eighty five dollars and 00/100
ORDER
OF
The City of Burlington
Memo: Erosion Control - PID 120791- 2.5 Acres
bbb
FIDELITY BANK
BURLINGTON, NC 27215
66-358/531
DATE AMOUNT
12/8/2021 $285.00
1
AUTHORRED SIGNATURE
II■000056541I 1:053 L035851:0 28 L003493II2
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